Lateral Heel Pain (For Dr. Splichal - kind of.........)

Haselsmasher

Barefooters
Apr 3, 2010
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[This is kind of directed to Dr. Splichal because it leverages off of a comment she made in the "PF Confusion" thread - but I'll obviously take anyone's input........]

For quite a while I've had a pain on my lateral heel. It's lower than the Post Tib tendon - right where the transition is from vertical surface to plantar surface. And while I call it lateral - it's also kind of on the transition between posterior heel and lateral heel.

I *did* have a stress reaction there about 9 months ago - but that seems to be resolved. The pain does flare up around the following scenarios:
  • The first few minutes after getting out of bed. Then it goes away after about 5-10 mins.
  • If I'm on my feet A LOT during the day (which is abnormal - I have a desk job) doing a lot of physical labor it can be sore at the end of the day. In those scenarios the next morning tends to have greater-than-normal morning pain.
  • It tends to increase if I've been running consistently. (For example - I currently have a cold and haven't been running - so it feels especially good now.) If it hurts as a result of consistently running it virtually never hurts while I'm actually running.
Dr. S - you commented about 1) fascia wrapping around and underneath the heel and 2) eccentric strength. Does this sound like it could be rooted in something like tightness and weak eccentric strength? Those two comments really resonated with me about being possible causes. If that makes sense - then would the recommendation of building eccentric strength be the right thing to pursue?

Thanks.

Jim

P.S.: My PT found a significant leg length discrepancy based on the fact the left side of my pelvis was rotated forward. And the problem spot I describe is on the left side. So I'm presuming that hip imbalance has contributed at least some amount to this problem.
 
Good question Jim!

I will do my best to answer your question without actually examining you (sometimes makes it a little tricky). When you are saying "lateral" and "posterior tibialis" - do you actually mean "medial" and "posterior tibialis" or "lateral" and "peroneals".

Either way if it is on the edge of the calcaneus/heel bone then it is most likely associated with the fascia of your calves. If it is on the medial side (inside) then these would be soleus fibers - if it is on the lateral side (outside) then these would be gastrocnemius fibers.

When we walk and stand we rely on the eccentric strength of the soleus which is why I see more patients complaining of this achilles tendonitis/plantar fasciitis on the medial (inside) of the foot. Eccentric strength would be very important in this case.

As far as your limb length discrepancy your PT found - what is "significant"? And is it functional or structural? Which side is longer? Has it ever been diagnosed by a Dr?

Good luck!
 
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My bad. I meant Peroneal Tendon. Sorry for the confusion. Given that clarification as well as what you put in your reply does that mean Gastroc fibers might be contributing to it - and also does your initial point also hold true that eccentric strength could play a role in this? As one possible relevant piece of history: I wore (all waking hours) completely rigid 3/4 length orthotics for about 12 or 13 years, and ran quite successfully in them during that time. But like many others the injuries kept piling up and my ability to get rid of them kept diminishing. I've been out of them for about 3 years. I'm still not running at the volume I want, and I believe it's because I think I'm STILL in the process of getting all of my systems used to moving and taking responsibility for movement.

Your "significant" question is a good one. My previous Podiatrist (~12 years ago) diagnosed the leg length discrepancy not via x-ray or anything like that but I think looking at my hips, etc. At that time he recommended a massive heel lift - to the point I took the shoe to a cobbler and had the heel built up. That was a complete disaster. My hips and hip flexors got so messed up I just abandoned those shoes and went back to the way things were. I don't recall what issue I was dealing with at the time - but I ran for many years with what he thought was a discrepancy that needed correcting. The bottom line: I don't know if it's functional or structural.

Thanks.

Jim
 
Ah that makes much more sense - peroneal tendons. The eccentric exercises are a bit more specific for medial foot pain and dysfunction as opposed to the lateral side of the foot.

Having said that, I do not know if your issue is the peroneal tendon or the gastrocnemius fibrous insertion along the lateral side of your calcaneus.

Why were you given orthotics? Do you have an over-pronated foot type? All of this is important when addressing the reason your gastroc insertion (or peroneals) are bothering you.

If you had a limb length discrepancy (LLD) that was so significant you had your shoe adjusted - then it is structural. If your physical therapist also saw a LLD get an actual number from him/her and ask if he thinks it is functional or structural. Both would be addressed slightly differently.

Keep me posted -
 
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Thanks so much for your help. I greatly appreciate it. I don't know when I'll see my PT next - hopefully this week. I'll ask her about degree of delta as well as structural vs functional on the LLD.

Below is a picture of me pointing to where the pain is. I presume, unless it's referred, that it's not the right place for Peroneal Tendon problems. Is this an area that fits with the Grastroc insertion you mentioned? I don't know if I have a pronated foot. I know I have very flat feet, as well as bunions. (My Podiastrist thinks the bunions will never be bad enough to require correction.) When the spot is sensitive dorsiflexing causes it to hurt - when I get to max dorsiflexion. One additional piece of data in case it gives a clue: When the spot on my heel is sore in the morning I tend to walk on the lateral side of my foot because that reduces the pain. If I let my foot collapse the pain is greater. After about 10-15 mins of walking things loosen up and I can walk normally with basically no pain. And then it continues to feel better as time goes on.

If it is the Gastroc issue you mention - is strength and making it looser (foam roller, heel drops, etc.) the way to improve it? It's really getting frustrating.

Thanks again.

Jim

PointingOnHeel800x600.jpg
 
A quick update - I just returned from my Podiatrist.

He believes it's Periostitis - an inflammation of the lining of the bone. With the pelvis repositioning he thinks it's further stretching some already tight tissues and that's aggravating the heel. He prescribed Voltaren gel to help calm it down and more PT - and potentially some dry needling as another method to help relieve the tension in the chain.

Hopefully that will help do the trick.

Jim

P.S.: I spoke with my PT. My LLD is functional. When she first found it she said the difference in leg length was 1/2". When she corrects the pelvis they go back to being even.
 
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Hi Jim -

The picture and additional information definately helps. The spot you are pointing to is the extension of the gastroc tendon fascia as it joins the plantar foot. In the human body connective tissue & fascia is continuous from the head to the foot so an imbalance in one part can / and will most definately influence other areas.

Voltaren gel is good and I prescribe it often to my patients. You will want to make sure you alleviate the increased stress on the plantar foot and gastroc fascia. Dry needling is good if you have true, deep trigger points or scar tissue that may be furthering your imbalance.

Do you do myofascial release now? I would do daily myofascial / or trigger point release to the bottom of the foot (stand on golf balls), to the peroneals, to the gastrocnemius, to the TFL and to the quads.

Good luck!!
 
I thought I'd post a follow-up:

I've been through 3 dry needling sessions and it has made a HUGE difference. My heel pain is almost completely gone. I follow-up and report this because, prior to getting dry needling, I thought my calves were in pretty good shape from a range of motion perspective. I've been rolling them for quite a while. However the needling uncovered some pretty significant knots in a variety of calf muscles, but especially the lateral gastroc, which correlates to what Dr. S said about those fibers going to the later heel.

Thanks again, Dr. Splichal, for the info.

If you're having chronic issues and think tightness might be contributing to it I'd most definitely recommend dry needling as a possible solution.

Jim
 
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Please explain dry needling.
 
Dry Needling is a muscle treatment for knots/trigger points/tightness. As I understand it trigger points are where a portion of the muscle goes into chronic, localized contraction. They (often?) can be felt - like a knot. An Accupuncture-like needle (maybe it is an actual Accupuncture needle) is inserted into the knot in the hopes that the needle interrupts the chronic nerve activity and causes the knot to relax. So especially if a muscle has multiple trigger points - needling can help a lot in getting the muscle to relax. My PT has told me that things like massage and foam rollering also gets rid of these trigger points, but sometimes they're deep or they just don't respond to those other treatments.

Some think this is Accpuncture or similar to it and from what I understand they're basically not related at all. Whereas I think Accupuncture needles are inserted and left in for a while, in general Dry Needling has the needles in for a short amount of time - probably 30-60 seconds. They're trying to elicit a muscle contraction - that's what happens when the knot lets go. Depending on the size of the contraction you kind of have to "breathe through it". LOL Most of the time I'm talking with the PT while he is doing it. When he found the big knot in my gastroc, when it was over, I realized I'd stopped talking - mid-sentence. He chuckled and said "Most people don't talk through those."

I'm making it sound (I think) bad or rough to go through and it's not.

Jim
 
[This is kind of directed to Dr. Splichal because it leverages off of a comment she made in the "PF Confusion" thread - but I'll obviously take anyone's input........]

For quite a while I've had a pain on my lateral heel. It's lower than the Post Tib tendon - right where the transition is from vertical surface to plantar surface. And while I call it lateral - it's also kind of on the transition between posterior heel and lateral heel.

I *did* have a stress reaction there about 9 months ago - but that seems to be resolved. The pain does flare up around the following scenarios:
  • The first few minutes after getting out of bed. Then it goes away after about 5-10 mins.
  • If I'm on my feet A LOT during the day (which is abnormal - I have a desk job) doing a lot of physical labor it can be sore at the end of the day. In those scenarios the next morning tends to have greater-than-normal morning pain.
  • It tends to increase if I've been running consistently. (For example - I currently have a cold and haven't been running - so it feels especially good now.) If it hurts as a result of consistently running it virtually never hurts while I'm actually running.
Dr. S - you commented about 1) fascia wrapping around and underneath the heel and 2) eccentric strength. Does this sound like it could be rooted in something like tightness and weak eccentric strength? Those two comments really resonated with me about being possible causes. If that makes sense - then would the recommendation of building eccentric strength be the right thing to pursue?


Thanks.

Jim

P.S.: My PT found a significant leg length discrepancy based on the fact the left side of my pelvis was rotated forward. And the problem spot I describe is on the left side. So I'm presuming that hip imbalance has contributed at least some amount to this problem.

One of the big mistakes made by many healthcare providers and their athletes as well is the obsession with where it hurts because this affects the way they can perform and function however, where it hurts is usually not the reason. While you will develop tendonosis or tissue thickening at the site of pain, especially in a heel, the reason usually exists in other parts of the body and the core is typically involved (your hip tipped forward with pelvic unleveling, for example).

There are obviously other larger problems at work and you are simply slamming your feet in the ground when you run (shod or not), causing the tendonosis. While the dry needling that has been spoken of in this thread may reduce the amount of tendonosis, it does not solve the core or the calf issues. Also, if the tissues around the ankle are stiff enough, the joints will lock, causing the knee to roll in and the hip to lock which will recruit into the oblique fascia and the ql on the opposite side. That affects both your lower stride (over and under striding) as well as causing the same with your arm movement. Tom Myers in his book anatomy trains has found fascial paths that explain these phenonenon quite well (there are other schools or thought on this but his is well accepted) and often when I follow his paths in treatment, I help more people overcome running problems.

My advice; your practitioner and you need to look beyond the obvious because no doing so will cause other injuries related to the same gait problems. Getting beyond the symptoms has huge rewards however, you need to find the right practitioner who understands the fascial system better.